Family History - National Institutes of Health



Indicate whether the participant/subject’s first and second degree blood relatives have a history of the following conditions.ConditionFamily History?Relationship of Family Member to Participant/ Subject(Choose all that apply from below list)Number of Affected Family MembersAlzheimer’s Disease/ Dementia FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteAmyotrophic Lateral Sclerosis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteAtaxia FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteAutism FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteBi-polar FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteCancer FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteDepression FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteDevelopmental Delays* FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteDiabetes FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteDuchenne Muscular Dystrophy or Becker Muscular Dystrophy FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteDystonia FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteEpilepsy Seizures* FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteHeadaches FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteHeart Disease FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteLearning Disability FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteMemory Loss FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteMultiple Sclerosis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteMuscle Disease* (not Duchenne Muscular Dystrophy or Becker Muscular Dystrophy) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteNeuromuscular Disease FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by sitePeripheral Neuropathy FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteParkinson’s disease FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteSchizophrenia FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteStroke FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteSuicide/Attempt FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteTourette syndrome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteOther, specify: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX Unknown/ UncertainData to be entered by siteData to be entered by siteIf there is a family history of Duchenne or Becker Muscular Dystrophy, complete the table below.Relative Relationship of Family Member to Participant/ Subject* NOTEREF _Ref395261260 \f \h 1(Choose all that apply from list below)Diagnosed?Age when diagnosed?(Years)Deceased?Current Age or Age at Death (if applicable)(in years)Cause of Death? FORMCHECKBOX Clinical Diagnosis FORMCHECKBOX Genetic Testing FORMCHECKBOX No FORMCHECKBOX Muscle Biopsy FORMCHECKBOX Obligate carrier based on family structure FORMCHECKBOX Don’t know/ Unsure FORMCHECKBOX No FORMCHECKBOX Not applicable(Years) FORMCHECKBOX Unknown FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteData to be entered by site FORMCHECKBOX Clinical Diagnosis FORMCHECKBOX Genetic Testing FORMCHECKBOX No FORMCHECKBOX Muscle Biopsy FORMCHECKBOX Obligate carrier based on family structure FORMCHECKBOX Don’t know/ Unsure FORMCHECKBOX No FORMCHECKBOX Not applicable(Years) FORMCHECKBOX Unknown FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteData to be entered by siteGeneral InstructionsInformation on each disease is gathered for blood relatives based on self-report from the participant/subject or family member.Specific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module. Other Condition, specify – If a family member has a condition not listed, specify the condition under "Other". Family History? – If there is a history of this condition in the family, indicate yes. Relationship of Family Member to Participant/Subject – Select the relationship from the options of the family members listed in the “Name of Family Member with Condition” column. Record more than 1 family member, if applicable. Number of Family Members – Enter total number of family members affected by the condition. Cause(s) of Death – Record the cause or causes of death using explanatory text and the associated ICD-9-CM code. Include the primary cause of death first followed by any secondary causes. ................
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